patient election to self-pay for services

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PATIENT ELECTION TO SELF-PAY FOR SERVICES

Patient First Name*

Patient Last Name*

Email*

Phone*

Insurance Company*

Certus Psychiatry and Integrated Care (“Clinic”) is a participating (in-network) provider with the provided insurance company.

Self-Pay Terms*

I agree to self-pay for services.

Certus Psychiatry and Integrated Care ("Clinic") is a participating provider with the aforementioned ("Company").

I, the undersigned patient, acknowledge that I understand and agree that:

I am currently enrolled in a health insurance plan through the Insurance Company that provides coverage for at least some of the psychiatric, counseling, or medical services offered by the Clinic.

The self-pay rates I have elected apply only to professional services (office visits, psychiatric evaluations, medication management, and individual/family counseling) provided by Clinic providers. They do not include separate charges for laboratory tests, diagnostic procedures, injections, medications administered or dispensed in the office, or any other ancillary services that may be ordered. These additional services will be billed separately (either to me or to my insurance, depending on my instructions for each service).

Even though my insurance plan may cover some or all of the professional services described above, I knowingly and voluntarily choose not to have the Clinic submit claims to my Insurance Company for these professional services.

I elect to pay the Clinic directly for the professional services listed in #3 at the Clinic’s discounted self-pay rates. This election remains in effect until I notify the Clinic in writing that I wish to revoke it and resume using my insurance benefits.

I understand that payments I make under this self-pay election will not count toward my health plan deductible, out-of-pocket maximum, or any other cost-sharing requirements, unless my specific insurance plan explicitly allows self-pay amounts to be credited (which is uncommon).

I have been informed of my payment options, including the option to use my insurance benefits. I have had the opportunity to ask questions about billing, coverage, and this self-pay election, and all of my questions have been answered to my satisfaction.